Opinion
No. 5:19-CV-00362-D
07-30-2020
Donald Williams, Plaintiff, v. Andrew Saul, Commissioner of Social Security, Defendant.
Memorandum & Recommendation
Plaintiff Donald Williams challenges Administrative Law Judge ("ALJ") Paula Wordsworth's denial of his application for social security income. Williams claims that ALJ Wordsworth erred in (1) determining his residual functional capacity ("RFC") and (2) failing to consider evidence inconsistent with her findings. Both Williams and Defendant Andrew Saul, Commissioner of Social Security, have moved for a judgment on the pleadings in their favor. D.E. 19, 21.
After reviewing the parties' arguments, the court has determined that ALJ Wordsworth erred in her determination. The undersigned cannot conclude that ALJ Wordsworth's RFC sufficiently addressed Williams's mental limitations, so this issue warrants more consideration upon remand. And ALJ Wordsworth failed to explain why she rejected certain evidence that conflicted with her findings. So the undersigned magistrate judge therefore recommends that the court grant Williams's motion, deny the Commissioner's motion, and remand this matter to the Commissioner for further consideration.
The court has referred this matter to the undersigned for entry of a Memorandum and Recommendation. 28 U.S.C. § 636(b).
I. Background
In April 2015, Williams applied for disability benefits and supplemental security income. In both applications, he alleged a disability that began in November 2013. The Social Security Administration denied his application at the initial level and upon reconsideration. Williams then appeared at a hearing before ALJ Wordsworth to determine whether he was entitled to benefits. ALJ Wordsworth determined that Williams was not entitled to benefits because he was not disabled. Tr. at 180-92.
ALJ Wordsworth found that Williams had several severe impairments: hypertension, neuropathy of the lower extremities, generalized anxiety disorder, and a history of alcohol use disorder. Tr. at 182. ALJ Wordsworth found that Williams's impairments, alone or in combination, did not meet or equal a Listing impairment. Tr. at 183.
ALJ Wordsworth determined that Williams had the RFC to perform a reduced range of light work. Tr. at 185. Williams can occasionally climb ramps and stairs, but he can never climb ladders, ropes, or scaffolds. Id. Williams can occasionally balance, but he cannot operate foot controls with the bilateral lower extremities. Id. And he must avoid concentrated exposure to workplace hazards that include unprotected heights and moving machinery. Id.
Williams is limited to simple, routine, repetitive tasks that involve no more than simple, short instructions and simple, work-related decisions with few workplace changes. Id. He can have occasional contact with supervisors, coworkers, and the public. Id. Williams requires the option to alternate between sitting and standing every two hours at his workstation, with standing and walking for four hours in an eight-hour workday. Id.
The decision limits Williams to "simple, work-related diction." Tr. at 185. But a review of the hearing transcripts shows that ALJ Wordsworth's hypothetical question to the Vocational Examiner involved a limitation to "simple, work-related decisions." Tr. at 223. The latter appears to be the correct limitation.
ALJ Wordsworth concluded that Williams could not perform his past work as a welder. Tr. at 190. But considering his age, education, work experience, and RFC, ALJ Wordsworth found that jobs existed in significant numbers in the national economy that Williams could perform. Tr. at 191. These include merchandise marker, mail sorter, and routing clerk. Id. Thus, ALJ Wordsworth found that Williams was not disabled. Id.
After unsuccessfully seeking review by the Appeals Council, Williams began this action in September 2019. D.E. 5.
II. Analysis
A. Standard for Review of the Acting Commissioner's Final Decision
When a social security claimant appeals a final decision of the Commissioner, the district court's review is limited to determining whether, based on the entire administrative record, there is substantial evidence to support the Commissioner's findings. 42 U.S.C. § 405(g); Richardson v. Perales, 402 U.S. 389, 401 (1971). Substantial evidence is defined as "evidence which a reasoning mind would accept as sufficient to support a particular conclusion." Shively v. Heckler, 739 F.2d 987, 989 (4th Cir. 1984) (quoting Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966)). If the Commissioner's decision is supported by the evidence, it must be affirmed. Williams v. Chater, 99 F.3d 635, 638 (4th Cir. 1996).
B. Standard for Evaluating Disability
In making a disability determination, the ALJ engages in a five-step evaluation process. 20 C.F.R. § 404.1520; see Johnson v. Barnhart, 434 F.3d 650 (4th Cir. 2005). The analysis requires the ALJ to consider the following enumerated factors sequentially. At step one, if the claimant is currently engaged in substantial gainful activity, the claim is denied. At step two, the claim is denied if the claimant does not have a severe impairment or combination of impairments significantly limiting him or her from performing basic work activities. At step three, the claimant's impairment is compared to those in the Listing of Impairments. See 20 C.F.R. Part 404, Subpart P, App. 1. If the impairment is listed in the Listing of Impairments or if it is equivalent to a listed impairment, disability is presumed. But if the claimant's impairment does not meet or equal a listed impairment, the ALJ assesses the claimant's RFC to determine, at step four, whether he can perform his past work despite his impairments. If the claimant cannot perform past relevant work, the analysis moves on to step five: establishing whether the claimant, based on his age, work experience, and RFC can perform other substantial gainful work. The burden of proof is on the claimant for the first four steps of this inquiry but shifts to the Commissioner at the fifth step. Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995).
C. Medical Background
Williams has a history of hypertension, neuropathy in his bilateral lower extremities, anxiety disorder, and a history of alcohol use disorder. Williams's hypertension caused him shortness of breath and chest pain. Tr. at 186. A cardiovascular examination yielded normal results. Id. And a January 2017 x-ray showed no acute cardiovascular abnormalities. Id.
Williams has reported numbness and tingling in his lower extremities. Id. Neurological testing noted generally normal results, such as a steady gait. Id. A June 2016 EMG found mild predominantly sensory axonal neuropathy. Id. Providers prescribed medication to Williams, which helped at controlling his symptoms. Id.
Dr. Gonzalo Fernandez performed a consultative examination in May 2016. Id. Williams reported hypertension, neuropathic leg pain, and numbness and tingling. Id. Dr. Fernandez found normal cardiovascular findings and remarked that Williams had a steady gait. Id. But Williams could not complete the heel to tiptoe walk. Id. Dr. Fernandez assessed hypertension and some lower extremity nerve damage, likely to be neuropathy. Id. Dr. Fernandez opined that Williams would have postural and environmental limitations because of his neuropathic pain and numbness. Id.
Later that month, Dr. Christopher Lacroix performed a second consultative examination. Tr. at 186. Noting Williams's history of alcohol use and neuropathic leg pain, Dr. Lacroix found decreased leg sensation and diminished balance. Id. But Williams could sit, stand, squat, and ambulate, and he retained full muscle strength and a normal gait. Id. Dr. Lacroix assessed Williams with alcohol abuse and lower extremity neuropathy. Id.
Dr. Lacroix opined that Williams could walk a block and climb a few steps with a handrail. Tr. at 189. He found that Williams had no exertional limitations but that he would have trouble moving about and traveling. Id.
Williams has suffered from alcoholism for over 20 years. Tr. at 186. He has three DWI convictions and has received in-patient treatment for alcohol-related seizures. Id.
In May 2016, Dr. Christopher Ricci performed a consultative examination. Id. Williams stated that he was restless and had trouble concentrating. Id. An examination found an apathetic affect, neutral mood, and clear sensorium. Tr. at 187. His attention, concentration, and recent memory appeared intact, but Williams's remote memory was impaired. Dr. Ricci also found that Williams's insight and judgment were below average. Id. He assessed an unspecified anxiety disorder and alcohol use disorder in early remission. Id.
Dr. Ricci opined that Williams could understand and follow some simple directions and instructions and he could perform some simple tasks independently. Tr. at 188. While Williams could maintain basic attention and concentration and keep a regular schedule, he would likely need significant training and supervision for complex tasks. Id. Williams could make appropriate decisions and relate adequately to others. Id. But he would have trouble with the stress of daily work activities. Tr. at 189.
In June 2016, providers assessed Williams with an anxiety disorder. Tr. at 185. His symptoms included restlessness, apprehension, a short temper, and racing thoughts. Id. But a mental status examination found he had an appropriate mood and affect. Id.
Four months later, Dr. Lance Fuller performed a consultative examination. Tr. at 187. Williams reported anxiety, insomnia, short-term memory problems, and feelings of worthlessness and hopelessness. Id. The mental status examination found that Williams was relaxed with effective eye contact. Id. His motor activity was a bit slowed and slightly lethargic with psychomotor agitation. Id. His thought process was mostly logical with some fragmentation. Id. Williams had good immediate recall but impaired delayed recall. Id. But his cognition and fund of knowledge were intact. Id.
Dr. Fuller opined that Williams would have trouble understanding, remembering, and following instructions and with sustaining attention to perform simple, repetitive tasks. Tr. at 189. Although he could relate to others, Dr. Fuller concluded that Williams would have trouble tolerating the stress and pressure of day-to-day work activities. Id.
Drs. Dakota Cox and Robert Pyle, state agency physicians, opined that Williams could perform medium work with postural and environmental limitations. Tr. at 188. State agency consultant Margaret Barnham, Ph.D., opined that Williams could perform simple, routine, repetitive tasks. Id. Although he had some difficulties with concentration, Dr. Barnham concluded that he could complete a normal workday with supervision. Id. Another state agency reviewer, Brett Fox, Psy.D., opined that Williams could understand, retain, and execute simple instructions, and maintain attention, concentration, persistence, or pace to complete simple tasks. Id. Dr. Fox further determined that Williams could interact appropriately with others and tolerate more routine workplace demands. Id.
At the hearing, Williams stated that the numbness in his feet limits his ability to sit and stand. Tr. at 185. He drinks every day, and more heavily on the weekends. Id. Williams reported alcohol-related seizures. Id. Despite his alcohol use, Williams could work. Id.
Williams can perform household chores like wash dishes, do laundry, prepare meals, and shop. Tr. at 187.
D. Residual Functional Capacity
Williams argues that ALJ Wordsworth failed to adequately account for his mental limitations in formulating the RFC. The Commissioner contends that the evidence supports ALJ Wordsworth's RFC finding. The undersigned finds that ALJ Wordsworth failed to explain how the RFC adequately addressed Williams's mental limitations.
The RFC is a determination, based on all the relevant medical and non-medical evidence, of what a claimant can still do despite her impairments; the assessment of a claimant's RFC is the responsibility of the ALJ. See 20 C.F.R. §§ 404.1520, 404.1545, 404.1546; Social Security Ruling ("SSR") 96-8p, 1996 WL 374184, at *2. If more than one impairment is present, the ALJ must consider all medically determinable impairments, including medically determinable impairments that are not "severe," when determining the claimant's RFC. Id. §§ 404.1545(a), 416.945(a). The ALJ must also consider the combined effect of all impairments without regard to whether any such impairment, if considered separately, would be of sufficient severity. Id. § 404.1523; see Walker v. Bowen, 889 F.2d 47, 50 (4th Cir. 1989) ("[I]n evaluating the effect[] of various impairments upon a disability benefit claimant, the [Commissioner] must consider the combined effect of a claimant's impairments and not fragmentize them.").
The ALJ must provide "findings and determinations sufficiently articulated to permit meaningful judicial review." DeLoatche v. Heckler, 715 F.2d 148, 150 (4th Cir. 1983); see also Wyatt v. Bowen, 887 F.2d 1082, 1989 WL 117940, at *4 (4th Cir. 1989) (per curiam). The ALJ's RFC determination "must include a narrative discussion describing how the evidence supports each conclusion, citing specific medical facts (e.g. laboratory findings) and nonmedical evidence (e.g. daily activities, observations)." Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015) (quoting SSR 96-8p). Furthermore, "[t]he record should include a discussion of which evidence the ALJ found credible and why, and specific application of the pertinent legal requirements to the record evidence." Radford v. Colvin, 734 F.3d 288, 295 (4th Cir. 2013). Fourth Circuit precedent "makes it clear that it is not [the court's] role to speculate as to how the ALJ applied the law to [her] findings or to hypothesize the ALJ's justifications that would perhaps find support in the record. Fox v. Colvin, 632 F. App'x 750, 755 (4th Cir. 2015).
In Mascio, the Fourth Circuit found that a limitation to simple, routine tasks or unskilled work may fail to address a moderate limitation in concentration, persistence, or pace. 780 F.3d at 638. The Fourth Circuit "agree[d] with other circuits that an ALJ does not account for a claimant's limitation in concentration, persistence, and pace by restricting the hypothetical question to simple, routine tasks or unskilled work" because "the ability to perform simple tasks differs from the ability to stay on task." Id. (quotation omitted). Because the ALJ failed to explain why the plaintiff's "moderate limitation in concentration, persistence, or pace at step three does not translate into a limitation in [plaintiff's] residual functional capacity," the Fourth Circuit remanded Mascio. Id. Although an ALJ's findings at step three may not require any additional limitations for concentration, persistence, or pace in the RFC, the ALJ must at least provide a sufficient explanation in the decision to allow the court to conduct meaningful review of the RFC determination. See Scruggs v. Colvin, No. 3:14-CV-466-MOC, 2015 WL 2250890, at *5 (W.D.N.C. May 13, 2015); Reinhardt v. Colvin, No. 3:14-CV-00488-MOC, 2015 WL 1756480, at *3 (W.D.N.C. Apr. 17, 2015).
At step three, ALJ Wordsworth noted that Williams's mental impairments caused moderate limitations in concentrating, persisting, or maintaining pace. Tr. at 184. The RFC limited Williams to simple, routine, repetitive tasks involving simple, short instructions and simple, work-related decisions; few workplace changes; and occasional interactions with others. Tr. at 185.
The Commissioner asserts that the additional mental limitations in the RFC distinguish this case from Mascio. Standing alone, a limitation to simple, routine tasks may not comply with Mascio because it does not sufficiently represent a moderate limitation in concentration, persistence, or pace. ALJ Wordsworth also limited Williams's instructions and decisions, workplace changes, and social encounters. But these added restrictions still appear inconsistent with Mascio's holding. See, e.g., Phillips v. Berryhill, No. 9:17-CV-01945-DCN, 2018 WL 6604228, at *4 (D.S.C. Dec. 17, 2018) (under Mascio and other cases, limitations to simple, routine, repetitive tasks, simple work-related instructions and decisions, few workplace changes, and occasional interactions do not address a claimant's limitations in concentration, persistence, or pace and his ability to work a full day); Carter v. Berryhill, No. 8:17-CV-01277-PMD-JDA, 2018 WL 3353069, at *9 (D.S.C. June 18, 2018) (remanding where ALJ failed to explain how a limitation to "simple, routine, repetitive tasks not performed in a fast paced production environment; involving only simple work-related instructions and decisions and relatively few work place changes" and to "occasional interaction with co-workers and members of the general public" addressed claimant's moderate difficulties in concentration, persistence, and pace because it did not discuss his ability to stay on task), adopted by, 2018 WL 3344649 (D.S.C. July 9, 2018); Thomas v. Colvin, No. 7:15-CV-101-KS, 2016 WL 5408114, at *3 (E.D.N.C. Sept. 28, 2016) (remanding case under Mascio where RFC limited claimant to simple, routine, repetitive tasks with infrequent and gradual changes and only casual interaction with the public because it did not fully account for claimant's moderate limitations in concentration, persistence, or pace).
Pointing to the recent Fourth Circuit decision in Shinaberry v. Saul, the Commissioner maintains that a limitation to simple, routine, repetitive tasks may sufficiently address a claimant's moderate limitations in concentration, persistence, or pace. 952 F.3d 113 (4th Cir. 2020). Shinaberry had borderline intellectual functioning that caused moderate limitations in concentration, persistence, or pace at step three. The RFC determination limited Shinaberry to simple, routine, repetitive tasks. Although Shinaberry asserted that the ALJ failed to consider her moderate limitation in concentrating, persisting, or maintaining pace, the ALJ found that additional mental restrictions were unwarranted. The ALJ observed that despite her lifelong borderline intellectual functioning and statements that she had trouble concentrating and completing tasks, Shinaberry's education, GPA, class rank, and IQ scores, coupled with her long work history as a cashier and sales associate, showed that limiting her to simple, routine, repetitive tasks addressed any deficits in her concentration, persistence, or pace.
But Shinaberry is distinguishable from the facts presented here. ALJ Wordsworth did not adequately explain how the RFC's mental restrictions addressed Williams's moderate limitations in this functional area. Her narrative discussion of the evidence does not clarify the issue. For instance, ALJ Wordsworth references generally normal findings upon mental status examination. Tr. at 186-87. And she noted that state agency reviews found that Williams could perform simple, routine, repetitive tasks despite his moderate limitations in concentration, persistence, or pace. Tr. at 188. ALJ Wordsworth remarked that Williams's demeanor during the hearing showed he could appropriately follow and answer questions. Tr. at 184. But none of these findings address Williams's ability to stay on-task for an eight-hour workday.
The Commissioner also contends that Williams has not shown that the RFC determination required additional limitations to account for his reduced ability to concentrate, persist, or maintain pace. But there is evidence that supports this conclusion. The record buttresses Williams's position that he would have trouble staying on-task. He reported restless and trouble concentrating to Dr. Ricci. An examination found that Williams's remote memory was impaired, and his insight and judgment were below average. Id. The next month, Williams's symptoms included restlessness, apprehension, a short temper, and racing thoughts.
In October 2016, Williams told Dr. Fuller that he had anxiety, insomnia, short-term memory problems, and feelings of worthlessness and hopelessness. Id. The mental status examination found that Williams's thought process was mostly logical with some fragmentation and impaired delayed recall. Id.
Dr. Ricci opined that Williams could understand and follow some simple directions and instructions and he could perform some simple tasks independently. And he would have trouble with the stress of daily work activities. Dr. Fuller opined that Williams would have trouble understanding, remembering, and following instructions and with sustaining attention to perform simple, repetitive tasks. Dr. Fuller also concluded that Williams would have trouble tolerating the stress and pressure of day-to-day work activities. State agency consultants Drs. Margaret Barnham, Ph.D., and Brett Fox, Psy.D., also noted Williams's difficulties with concentration.
These opinions constitute contradictory evidence that casts uncertainty on Williams's mental functional abilities. Thus, ALJ Wordsworth needed to examine Williams's ability to stay on-task and explain her reasons for rejecting these providers' findings, not merely identify the evidence and set forth her conclusions.
The additional restrictions for instructions, decisions, changes, and interactions may not address the functional domain of concentrating, persisting, or maintaining pace on which Mascio focused. Limiting Williams to short, simple instructions and simple, work-related decisions relates to his mild limitations in understanding, remembering, and applying information. See 20 C.F.R. Pt. 404, Subpt. P, App'x 1 § 12.00(E)(1) (this domain "refers to the abilities to learn, recall, and use information to perform work activities. Examples include understanding and learning terms, instructions, procedures . . . and using reason and judgment to make work-related decisions."). Occasional interactions with others appear to fall within the domain of interacting with others. Id. § 12.00(E)(2) (this area refers to abilities to relate to and work with supervisors, co-workers, and the public). In any event, these restrictions do not address Williams's ability to maintain concentration, persistence, or pace. Varga v. Colvin, 794 F.3d 809, 815 (7th Cir. 2015) ("'Few if any work place changes' with limited 'interaction with coworkers or supervisors' deals largely with workplace adaptation, rather than concentration, pace, or persistence.")
The undersigned cannot agree that limitations set forth in ALJ Wordsworth's RFC determination for simple, routine, repetitive tasks; short, simple instructions; simple decisions; and limited workplace changes and interactions reflect Williams's moderate limitations in concentration, persistence, or pace found at step three. As noted above, courts have found such limitations may not follow Mascio's holding. Without an explanation, it is unclear if ALJ Wordsworth omitted or overlooked Williams's functional abilities in this domain or determined that the step three findings do not translate into more restrictions in the RFC.
Thus, the Mascio determination supports remand here. So the undersigned recommends that the court grant Williams's argument on this issue.
E. Conflicting Evidence
Williams next argues that ALJ Wordsworth failed to explain why she discounted evidence that conflicted with her RFC determination. The Commissioner claims that ALJ Wordsworth considered all the evidence, both favorable and unfavorable, in making her decision. The undersigned finds that ALJ Wordsworth failed to adequately explain why she declined to endorse some medical opinions inconsistent with the RFC determination.
Social Security Ruling 96-8p explains how adjudicators should assess residual functional capacity. The Ruling instructs that the residual functional capacity "assessment must first identify the individual's functional limitations or restrictions and assess his or her work-related abilities on a function-by-function basis, including the functions" listed in the regulations. "Only after that may [residual functional capacity] be expressed in terms of the exertional levels of work, sedentary, light, medium, heavy, and very heavy." SSR 96-8p. The Ruling further explains that the residual functional capacity "assessment must include a narrative discussion describing how the evidence supports each conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily activities, observations)." Id.
There is no "per se rule requiring remand when the ALJ does not perform an explicit function-by-function analysis[.]" Mascio, 780 F.3d at 636. But "[r]emand may be appropriate . . . where an ALJ fails to assess a claimant's capacity to perform relevant functions, despite contradictory evidence in the record, or where other inadequacies in the ALJ's analysis frustrate meaningful review." Id. (quoting Cichocki v. Astrue, 729 F.3d 172, 177 (2d Cir. 2013)). The function-by-function requirement can be satisfied by reference to a properly conducted analysis by a state agency consultant. See, e.g., Linares v. Colvin, No. 5:14-CV-00129, 2015 WL 4389533, at *3 (W.D.N.C. July 17, 2015) ("Because the ALJ based his RFC finding, in part, on the function-by-function analysis of the State agency consultant, the ALJ's function-by-function analysis complied with [SSR] 96-8p." (citing Lemken v. Astrue, No. 5:07-CV-33-RLV-DCK, 2010 WL 5057130, at *8 (W.D.N.C. July 26, 2010))).
Dr. Fuller opined that Williams would have trouble understanding, remembering, and following instructions and with sustaining attention to perform simple, repetitive tasks. He also concluded that Williams would have trouble tolerating the stress and pressure of day-to-day work activities.
ALJ Wordsworth gave little weight to this assessment. Tr. at 189. She noted that Dr. Fuller failed to specify how alcohol would interfere with Williams's functioning and the recent diagnosis of anxiety, his only other mental health condition. Id.
These reasons to discount this opinion do not stand up to scrutiny. First, ALJ Wordsworth did not find that other medical opinions more persuasive because they addressed the effect of Williams's alcohol use on his functioning.
Dr. Ricci found that Williams's memory was mildly to moderately impaired, possibly caused by long term alcohol use, but that condition was in early remission. Tr. at 187.
And the temporal proximity of Williams's anxiety diagnosis to Dr. Fuller's consultative examination does little to discredit his conclusions. Several months before Dr. Fuller's examination, Williams had reported symptoms associated with this condition, including anxiousness, insomnia, short-term memory problems, restlessness, apprehension, a short temper, racing thoughts, and trouble concentrating. Examinations noted some fragmentation in his thought process, impaired remote memory, and below average insight and judgment.
And Dr. Ricci, whose opinion ALJ Wordsworth gave significant weight, opined that Williams could perform some simple tasks and would have trouble with the stress of daily work activities. ALJ Wordsworth declined to adopt these findings. ALJ Wordsworth did not explain why she felt other limitations Dr. Ricci assessed were persuasive, yet these restrictions were not.
In sum, the record supports finding that Williams is more limited that the RFC reflects. But ALJ Wordsworth did not offer sound reasons why she found evidence inconsistent with the RFC determination unpersuasive. This issue warrants more consideration of evidence related to Williams's mental functioning abilities. So the undersigned recommends the court remand the matter on this issue.
III. Conclusion
For these reasons, the undersigned recommends that the court grant Williams's Motion for Judgment on the Pleadings (D.E. 19), deny Saul's Motion for Judgment on the Pleadings (D.E. 21), and remand the matter to the Commissioner for further consideration.
The Clerk of Court must serve a copy of this Memorandum and Recommendation ("M&R") on each party who has appeared in this action. Any party may file a written objection to the M&R within 14 days from the date the Clerk serves it on them. The objection must specifically note the portion of the M&R that the party objects to and the reasons for their objection. Any other party may respond to the objection within 14 days from the date the objecting party serves it on them. The district judge will review the objection and make their own determination about the matter that is the subject of the objection. If a party does not file a timely written objection, the party will have forfeited their ability to have the M&R (or a later decision based on the M&R) reviewed by the Court of Appeals. Dated: July 30, 2020
/s/_________
Robert T. Numbers, II
United States Magistrate Judge